Trauma Resuscitation — Airway, Cervical Spine (C-Spine), Breathing — Clinical Pathway: Emergency

Trauma Resuscitation Clinical Pathway — Emergency Department

Airway, Cervical Spine (C-Spine), Breathing

Goal

  • Avoid hypoxia and hyperventilation
    • Clear airway with suction as needed
    • Give 100% oxygen via mask/nasal cannula
    • Continuously monitor vital signs including pulse oximetry, ETCO2
    • Assure appropriate size bag & mask with associated oral/nasal airways available
    • Assure laryngeal mask and intubation equipment are prepared
C-Spine Immobilization
  • Consider unstable in most patients until proven otherwise and immobilize. Patients with concern for cervical spine injury should have:
    • Second provider holding inline stabilization
    • Cervical collar removed from the front of the neck to prevent inhibiting movement of soft tissues and mandible forward
Indications for Intubation
  • Concern for:
    • Deteriorating mental status
    • Glasgow Coma Scale < 8
    • Airway obstruction
    • Poor respiration without likelihood of imminent reversal
    • Respiratory distress
    • Inability to ventilate effectively by other means
    • Penetrating neck trauma
Pre-Intubation Planning MonitorsSuctionOxygen AirwaysPharmacy
Sedatives
  • Etomidate 0.3 mg/kg IV
  • Onset 30-60 sec
  • Duration 3-5 min
  • Avoid if there is danger of sepsis
  • Onset 30 sec
  • Duration 5-10 min
Paralytics
  • Rocuronium 1.2 mg/kg IV
  • Onset 30-60 sec
  • Duration 20-30 min
  • Vecuronium 0.1-0. 2mg/kg IV
  • Onset 2-3 min
  • Duration 20-40 min
  • Succinylcholine 1-2 mg/kg IV
  • Onset 30-60 sec
  • Duration 4-6 min
  • Bag available from emergency department (ED) pharmacy
  • Watch for hyperkalemia and malignant hyperthermia
  • Avoid in crush injuries
  • Can be given IM (2-4 mg/kg) with onset 3-4 min; duration 10-30 min
Intubation
  • Pre-oxygenation
  • Avoid hypotension
  • Positioning
  • Cervical spine immobilization
  • Suctioning
  • Laryngoscopy
  • Endotracheal placement
Cuffed Endotracheal Tube Size Recommendations
Patient Age Yrs Tube Size
≥ 2 3.5 mm tube + (age in years /4)
1 - < 2 3.5 mm tube
< 1 3.0 mm tube
Confirming Tube Placement
  • Patient arrives intubated, unstable:
    • Confirm ETT position by laryngoscopy, ETCO2, auscultation, ETT depth, chest X-ray (CXR)
  • Patient arrives intubated and stable:
    • Confirm ETT position by ETCO2, auscultation, depth evaluation, CXR
  • Patient intubated in the ED:
    • Confirm placement with a video laryngoscope w/ trans-laryngeal tube
    • ETCO2, auscultation, depth evaluation, CXR
Breathing Ventilations per minute by age
Goals
RR Normal for age
SpO2 > 92% and ≤ 98%
ETCO2 30-34 mmHg — If head injury with concern for increased ICP
35-40 mmHg — If no head injury